This Angel is pissed off. I'm Nurse Anne and I work on large general medical ward in the NHS. These are the wards with the most issues surrounding nursing care. The problems are mostly down to intentional understaffing by hospital chiefs that result in a lack of real nurses on the wards.
"The martyr sacrifices themselves entirely in vain. Or rather not in vain, for they merely make the selfish more selfish, the lazy more lazy and the narrow more narrow"-Florence Nightengale

Thursday, 21 May 2009

Why does caring burn us out?

"Before I sign off, one of my readers asked me to help him out. Edward J Gordon, RN is doing some research for a book and he wants to hear from you. The book is about burnout. I’m sure most of you know what that is. Here’s what Edward said:

I sure would like to understand what’s at the heart of burnout. What is it that kills us about nursing? What is it that makes us so unhappy? Almost everyone I work with is either trying to get into NP school, or CRNA school, or is already taking classes-as if there were some unlimited amount of jobs away from the bedside. I think if I were younger and wanted to leave the bedside, I’d leave nursing altogether, become an IRS agent or something (I like numbers.). It seems like caring kills. It kills us personally to care for others. It turns us into something we are not. But is that a bad thing or a good thing? And is it this kind-of spiritual suicide that’s at the heart of burnout? I’m just wondering.

Please send Edward an email at EdGordonRN@cableone.net if you can help him out."Nurse Anne decided to email Ed. I basically summed up the reason for this blog and made my usual amount of typos due to the fact that I am always in a rush. I know I simply told him things that he already knows, and I doubt that my email is really what he is looking for, but I sent the email anyway.

It went something like this:

Dear Ed,

Why do nurses burn out?

Nurses are expected to take on a ridiculous number of patients. At the same time they are expected to treat each and every patient as if they are the only patient on the floor. It is an impossible task and that is what burns nurses out.

We get the most wicked abuse when we are unable to provide this level of care from patients, families, our managers, the media etc. Here in the UK they will staff a 25- 35 acute medical ward that has a significantly high number of elderly, dependent patients with dementia with 2 RN's only. If we are lucky we may get 2 or 3 care assistants to help. We don't even get a ward clerk to answer the phones anymore as management does not want to pay for it. This is getting normal for general medical surgical floors in the NHS. It is definitely the norm for wards that have a high number of elderly patients.

I cannot remember the last time we had more than 2 RN's on duty for the whole floor.

If you open the newspapers here in England you will read countless articles about the suffering of patients in hospital. They claim that the nurses are uncaring and lazy and that this the whole cause of the problem. They claim that the whole problem is that nurses are better educated these days, and that we think we are above mopping the floors and caring for patient's basic needs. They claim that this is the reason MRSA and cdiff are rampant. This is what people think.

We are often left with critically ill patients during mealtime and 2 nurses and 2 care assistants to feed 18 people. We get a 20 minute window at mealtime to get all the food out and feed the patients. The critically ill patients do not go away at this time. What to do? What to do?

The press and various patient rights groups are claiming that nurses these days think that they are "too clever to do something so menial as feed patients" and say that this is the reason that patients are starving. They hit us up with these insane patient loads and then they say that if we are not sitting at bedsides mopping brows and holding hands it is because we are all cruel. We often work 14 hour days without a break and without stopping and still cannot get anything done. let alone done well.

People do not realise that nurses have life and death responsibility on their shoulders and that every second counts. They place unrealistic and unfair demands on the nurses, and then they lauch direct attacks towards the nurses when their unrealistic demands are not met. This is why "caring" burns us all out. This is why our nurses are running away from the bedside. I blog about this if you ever want to have a read. I'll just warn you about my language. I do tend to swear like a sailor at times. I don't swear normally, bad language just seems to rear it's ugly head when I blog.

39 comments:

Too much responsibility with little real power. Therefore damned if we do, damned if we don't.Sadly, people will only truly realise what they have lost when the nhs is privatised and what they directly pay for or can afford is what they get. My sixteen year old son has seen what nursing has done / is doing to me and he will be training to be an electrician. For that i am truly glad.

There are good places too. I recently switched jobs from a Godawful general hospital that suffered from all the horrors Nurse Anne describes to a small specialist hospital with SEVEN (count em SEVEN) RGN's on every shift plus a Ward Manager (not counted in the numbers) and at least one HCA. This on a 25- bedded ward. I was gobsmacked.Take my advice, find yourself a nice tertiary centre with no A&E . I'm loving every second of my new job.

I would add another long-term problem which bears on your comment: this is the separation between nursing education, nursing management and nursing practice. Instead of being an integrated profession nursing has allowed itself to be fragmented into almost antagonistic groups to the detriment of patient care and the profession itself.

Nurse Anne, how thick are you really? You can read, you can write, you can sling abuse but I'm not sure you can think.

I think that if nursing was an integrated profession with no separation between management, education and clinical nursing managers would NOT crucified when they tried to help the "floor nurses." Managers would be leading and managing from the "floor." The matrons you attacked in a previous post would be active in hands-on nursing. As for nurse education, of course it's relevant, but I didn't say it wasn't so what are you on about? My point was that I think it would be better if nurse education, and therefore nurse teachers, could find ways of working more closely with clinical nurses and patients than they do at the moment.

So from your comment it seems that you think that the present relationship between clinical nursing, management and education is OK? Wow... your matrons, your managers, all working hard to support you in your work... all fully informed about your staffing needs... all supporting you when things get difficult... I must have missed those posts.

If you disagree with me try writing a coherent response. You'll find it a bit difficult but it'll be worth the effort.

Yes, I agree Anonymous, it sounds like abuse, or it could be a reasonable question based on the evidence. You can take your pick. In any case, I think I can claim that I was only responding in kind. Having got that out of the way, what about addressing the topic?

Government targets and hospital management has fragmented groups within nursing. Senior nursing staff develop blurred priorities as they climb the career ladder. Targets become the priority of the day. I have observed good staff nurses become target driven monkeys in charge.

Happy1: If I said that I agreed with you, and that I don't see much incompatibility between your comment and mine I'd be called a "twat" and Anne would say that I'm "so full of crap" so I'm a bit stuck for a worthwhile comment.

Glam's comment is entirely relevant. S/He is correct about the widely differing priorities of nursing education (which teaches ideal practice), nursing management (which chases ludicrous government targets) and nursing practice )us poor buggers on the wards)Nurses, and there are a LOT of us could potentially be as powerful an organisation as the Police Association but we seem to waste this potential in petty infighting.

What is the climate for unions in nursing in the UK? Do you guys have one? Sounds like you may need one. I live in a state in the US that is very anti-union. So I know that's easier said than done. Just wondering what it's like over there.

To Anonymous 17.45 in the US: Yes we do indeed have nursing unions in the UK and in theory they are quite strong, with a number of legal rights. In practice their strength is compromised because members are reluctant to take action against management that could affect patient care.

On the other hand you don't always have to strike to get things done and strong union branches can bring about useful local improvements when members are active. Anne on this blog just says unions are useless; I say that unions are only useless when members allow them to be and the answer to a useless local union is to kick out the existing officers and vote in new ones. As Anonymous 10.48 observes (thank you), nurses have a huge amount of potential power in the NHS, much of which is wasted on petty infighting.

Glam does have a point although I am not sure I would agree with you re. education.. There are some recent moves to integrate clinical practice and education following concerns that student nurses were lacking basic nursing skills. However, I believe it's up to nurses & tutors to help reduce this gap. I work as the link between my team and the school of nursing. Hence I am up to speed regarding the clinical area and I make efforts to keep up to speed with the latest in the education arena. It does depend upon the individual and the level of managerial support that allows one to do this. But for many of my colleagues the school of nursing is viewed as ivory towersville and lacking in credibility. I see some of the tutors but my colleagues rarely see them. But there is a greater emphasis over the past year to utilise the experiences and knowledge of clinical staff. The latter are also having to take more responsibility for their practice as student mentors. Interestingly, I have seen this smoke out some of the lazier staff who have tended to take a back seat with student nurses. But most clinical staff I know continue to educate themselves, both formally and informally. As for management....I am currently working in a managerial secondment for six months and it is a different world. There is a real separation between management & clinical practice. The longer one is removed from day to day clinical practice the more one is removed from the realities of the job and it becomes a question of targets, figures, resources, etc...Happily my role will end after six months and I am choosing to return to clinical practice.Mind you, I do work in community mental health so that is a long way removed from the general medical ward. Our team was recently accused by a care home manager (general trained:it showed) of being "do gooding social workers" (my colleagues are social workers) my experiences & perspectives will be very different from the average general nurse.

Actually mate, Anne's right - I get sick of hearing pseudo-intellectual waffle about how nursing has fragmented and so on. The simple fact is, if you work in a nice, well staffed smaller unit the job is great. If you are one of the plebs in the front line in a medical ward they take the fucking piss out of you day after day after day - the matrons etc know but can do fuck all about it and are just glad they themselves are out of it.

I'm around. My computer is absolutely fucked but we are about to buy a new one. It actually had smoke coming out of it a few days ago. As soon as the new comp is up and running I will be back. I always have plenty to say!!!

Okay. Hubby just built the new computer. That was the problem. He wanted to build one rather than buy one. To my surprise, he has done a good job.

I am going mad over having 10 different relatives ringing the ward every hour and demanding that the nurse stop what she is doing to speak to them. Why can't they just speak to eachother? If they cannot speak to eachother for whatever reason why should my patient's safety and my registration be put at risk.

I realised that everything I try and do throughout a shift has to be done as a rush job during the 30seconds I have between uncontrollable interruptions.

I doubt that the majority hold the opinion that ‘they hit us up with these insane patient loads and then they say that if we are not sitting at bedsides mopping brows and holding hands it is because we are all cruel.’

People are aware of the stress that comes with jobs in the medical field; it’s simply common sense that treating and caring for sick people takes a lot of work.

If they did I never would have been driven to write this blog.I deal with their behaviour day after day.

People have no understanding whatsoever of how many things a nurse has to accomplish during the course of a shift,or how little control they have. Nor do they understand the consequences that can occur when the nurses fail.

If they did understand these things, their behaviour would be different.

I work as a consultant in acute geriatrics. My ward nurses are run off their feet and exhausted. I haven't done a ward round with a nurse for 2 years as they are too busy so I don't insist. There are so many communication errors, mistakes and delayed discharges. I have tried writing to managers, complaining to the 'matron' (once my excellent ward sister but she now says she prefers her current role where she seems unable to recruit or support ward nurses), stating that there are not enough nurses per shift. Everyone says either 'it's not affordable/it's not financially sustainable' (ie patient safety and good care is not affordable!!), or that they just can't do anything about it. My last attempt was a 4 page document to the managers putting the case that one more RN per shift would save them money in discharge delays. No one will listen. I get so angry for my patients and nurses, it's like balancing on a tightrope over an abyss all the time.

And there's nothing wrong with a ward sister going for promotion to matron, she deserves a pay rise and more recognition, all nurses have the right to seek promotion but I mourn the loss of an outstanding irreplaceable ward sister

It's certainly a somewhat recession proof field right now. Sites like http://www.unitedanesthesia.com/ show evidence that every state is still looking for qualified CRNAs (and willing to pay for them too). Hardly something that every industry can claim right now.

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In an atmosphere if universal deceit telling the truth is a revolutionary act. George Orwell.

Why has Nursing Care Deteriorated

Good nurses are failing every day to provide their patients with a decent standard of care. You want to know what has happened? Read this book and understand that similiar things have happened in the UK. Similiar causes, similiar consequences. And remember this. The failings in care have nothing to do with educated nurses or nurses who don't care. We need more well educated nurses on the wards rather than intentional short staffing by management.

About Me

I am a university educated registered nurse. We had a hell of a lot of hands on practice as well as our academic courses. The only people who say that you don't need a brain or an education to be an RN are the people who do not have any direct experience of nursing in acute care on today's wards. I have yet to meet a nurse who thinks that she is above providing basic care. I work with nurses who are completely unable to provide basic care due to ward conditions.
I have lived and worked in 3 countries and have seen more similarities than differences. I have been a qualified nurse for nearly 15 years. I never used to use foul language until working on the wards got to me. It's a mess everywhere, not just the NHS.
Hospital management is slashing the numbers of staff on the ward whilst filling us up with more patients than we can handle... patients who are increasingly frail. After an 8-14 hour shift without stopping once we have still barely scratched the surface of being able to do what we need to do for our patients.

Quotes of Interest. Education of Nurses.

Hospitals with higher proportions of baccalaureate-prepared nurses tended to have lower 30-day mortality rates. Our findings indicated that a 10% increase in the proportion of baccalaureate prepared nurses was associated with 9 fewer deaths for every 1,000 discharged patients."...Journal of advanced nursing 2007

THIS MEANS WE NEED WELL EDUCATED NURSES AT THE BEDSIDE NOT IN ADVANCED ROLES

Dr. Linda Aiken and her colleagues at the University of Pennsylvania identified a clear link between higher levels of nursing education and better patient outcomes. This extensive study found that surgical patients have a "substantial survival advantage" if treated in hospitals with higher proportions of nurses educated at the baccalaureate or higher degree level.

THIS MEANS WE NEED WELL EDUCATED NURSES AT THE BEDSIDE NOT IN ADVANCED ROLES

Dr. Linda Aiken and her colleagues at the University of Pennsylvania's Center for Health Outcomes and Policy Research found that patients experienced significantly lower mortality and failure to rescue rates in hospitals where more highly educated nurses are providing direct patient care.

Evidence shows that nursing education level is a factor in patient safety and quality of care. As cited in the report When Care Becomes a Burden released by the Milbank Memorial Fund in 2001, two separate studies conducted in 1996 - one by the state of New York and one by the state of Texas - clearly show that significantly higher levels of medication errors and procedural violations are committed by nurses prepared at the associate degree and diploma levels as compared with the baccalaureate level.

Registered Nurse Staffing Ratios

International Council of Nurses Fact Sheet:

In a given unit the optimal workload for a registered nurse was four patients. Increasing the workload to 6 resulted in patients being 14% more likely to die within 30 days of admission.

A workload of 8 patients versus 4 was associated with a 31% increase in mortality. (In the NHS RN's each have anywhere from 10-35 patients per RN. It doesn't need to be this way..Anne)

Registered Nurses in NHS hospitals usually have between 10 and 30+ patients each on general wards.

Earlier in the year, the New England Journal of Medicine published results from another study of similar genre reported by a different group of nurse researchers. In that paper, Needleman et al3 examined whether different levels of nurse staffing are related to a patient’s risk of developing complications or of dying. Data from more than 5 million medical patient discharges and more than 1.1 million surgical patient discharges from 799 hospitals in 11 different states revealed that patients receiving more care from RNs (compared to licensed practical nurses and nurses’ aides) and those receiving the most hours of care per day from RNs experienced fewer complications and lower mortality rates than those who received more of their care from licensed practical nurses and/or aides. Specifically for medical patients, those who received more hours per day of care from an RN and/or those who had a greater proportions of their care provided by RNs experienced statistically significant shorter length of stay and lower complication rates (urinary tract infections, gastrointestinal bleeding, pneumonia, cardiac arrest, or shock), as well as fewer deaths from these and other (sepsis, deep vein thrombosis) complications

•Lower levels of hospital registered nurse staffing are associated with more adverse outcomes such as Pneumonia, pressure sores and death.
•Patients have higher acuity, yet the skill levels of the nursing staff have declined as hospitals replace RN's with untrained carers.
•Higher acuity patients and the added responsibilities that come with them increase the registered nurse workload.
•Avoidable adverse outcomes such as pneumonia can raise treatment costs by up to $28,000.
•Hiring more RNs does not decrease profits. (Hospital bosses don't understand this. They think that they will save money by shedding real nurses in favour of carers and assistants. The damage done to the patients as a result of this costs more moneyi.e expensive deaths, complications,and lawsuits, and complaints....Anne)

Disclaimer

I know I swear too much. I am truly very sorry if you are offended. Please do not visit my blog if foul language upsets you. I want to help people. That is why I started this blog and that is why I became a Nurse. I won't run away from Nursing just yet. I want to stick around and make things better. I don't want the nurses caring for me when I am sick working in the same conditions that I am. Of course this is all just a figmant of my imagination anyway and I am not even in this reality. Or am I?Any opinions expressed in my posts are mine and mine alone and do not represent the viewpoint of the NHS, the RCN, God, or anyone else.